Credentialing: A cautionary tale of an essential business process

Particularly when providers are setting up a new practice, one of the things they know they need to do is credentialing enrollment for every physician and other eligible provider (mid-level physician assistants, nurse practitioners, etc.) — with each insurance plan they accept, for each facility they practice in. Then they tend to forget about it.

Big mistake.

Credentialing is the foundation for proper billing and getting paid the correct amount in a timely fashion. If changes have been made — you’ve added or had providers leave, they now practice in different locations, your pay-to address changes, or the payer itself changes some detail — things don’t line up and your reimbursements can be frozen…sometimes for months.

For a small practice that moves quickly, that may be “only” $4,000 or $5,000 in delayed or reduced payments. That relatively low amount can still be devastating to a practice or clinic operating on a razor-thin margin. But for larger organizations, a delay in Medicaid payments could be 150 days, and have a significant impact on your cash flow.

I’ve found that since providers have so much to focus on as they serve their patients and keep their business’ doors open, not keeping their credentialing totally up to date can be easily overlooked, and can have devastating consequences.

CAQH: A valuable resource

If this all sounds like more than a practice small or large can comfortably handle, it can be. Fortunately, there’s a valuable resource that we point our clients to — the Council for Affordable Quality Healthcare or CAQH, a Washington, DC-based non-profit alliance. CAQH hosts a website where providers can easily post and update their certification information — licensure, certificate of insurance and other data required by payers. Though it must be updated at least quarterly, it’s a far easier way to achieve and maintain certification than having to provide the information to each health plan for every provider in every facility in every market that those providers cover.

CAQH’s Committee on Operating Rules for Information Exchange, also known as CAQH CORE, develops administrative operating rules shared by healthcare providers, plans, government agencies and the organizations to set standards for healthcare and data exchange. It also provides a voluntary certification program so organizations can demonstrate they have adopted and are adhering to those rules and standards, and that all data is current and accurate.

The CAQH website is the first place payers go to ensure alignment with the credentialing and billing information providers submit; if there’s not a match, however small, payments are placed on hold. There goes your cash flow and days in A/R.

How the Advantum team Helps

As noted, credentialing and any issues that may arise can be easily and quickly remedied or can take an expensive 150 days or more to resolve. The Advantum Health credentialing team gets involved in one of two scenarios:

Credentialing services to ensure that updates for the practice, its providers and payers are made before it becomes a payment issue. For instance, if you’re an active credentialing client, we work to ensure that your Medicare enrollment is never We help ensure you don’t run the very real risk of losing some of your back payments through the Medicare re-validation process.

Emergency support: When a payer notifies a practice managing its own credentialing of a problem, our expert team — currently totaling about a dozen people — can be brought in to help uncover and rectify the situation and get payments flowing again ASAP.

Either way, the constantly changing nature of healthcare often means there is little time to prepare for changes as they occur. For instance, if due to lack of clarity about the Affordable Care Act or any replacement causes a payer deciding to change, add a plan or leave a market, providers may receive notifications in October that will take effect Jan. 1. Most practices simply can’t be expected to have the resources and infrastructure already established in-house to get all affected contracts and changes loaded efficiently.

Obviously, the first, proactive approach is in a practice’s best interest…having eagle-eyed experts watching market trends and your practice to prevent problems before they occur and deal with them immediately. But we’re glad to offer the “emergency” support services as well.

‘Making sure you’re paid the very best’

I’m often asked what our credentialing team does. Simply put, I say “We make sure that practices, clinics and providers get paid, and help them jump through whatever hoops are required to get and keep them that way. I say our motto should be ‘making sure we get you paid the very best’.”

I’m very proud of what we do for our clients…providing them with the confidence that they know this critical and ever-changing function is done and done correctly, that they understand it’s a continuous process and ongoing maintenance, not a one-and-done thing. And that they know credentialing support is an investment in an expert service to ease your administrative burden and ensure your business is being well-cared-for.

If you don’t have the resources to credential internally or you consider it a pain and would rather not deal with it, talk to us to learn more about how our expert staff can take the weight off your shoulders. For more information on Advantum Health’s credentialing services, email me at SWilson@advantumhealth.com.